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We investigated long-term outcomes of bicuspid aortic valve (BAV) repair, with external annuloplasty, according to aorta phenotype.Between 2003 and 2020, all patients with BAV operated on for aortic insufficiency (AI) and/or aneurysm were included. Repairs included isolated AI repair with subvalvular with or without sinotubular junction (STJ) (single or double) annuloplasty, supracoronary aorta replacement (with or without hemiroot remodeling), and root remodeling with external subvalvular ring annuloplasty.Among 343 patients operated, reparability rate was 81.3% (n = 279; age 46 ± 13.3 years). At 10 years (median follow-up: 3.42 years; interquartile range, 1.1, 5.8), survival was 93.9% (n = 8 deaths, similar to general population), cumulative incidence of reoperation was 6.2% (n = 10), AI grade2 was 5.8% (n = 9), and grade1 was 23.0% (n = 30). BAV repair stabilizing both the annulus and STJ with annuloplasty, compared with nonstabilized STJ repair (single annuloplasty), had lower incidence of reoperation (2.6% vs 22.5%, P = .0018) and AI grade2 (1.2% vs 23.6%, P .001) at 9 years. Initial commissural angle160° was not a risk factor for reoperation, compared with angle ≥160° if symmetrical repair was achieved (2.7% and 4.1%, respectively, at 6 years, P = .85). Multivariable model showed that absence of STJ stabilization (odds ratio, 6.7; 95% confidence interval, 2.1-20, P = .001) increased recurrent AI, but not initial commissural angle160° (odds ratio, 1.01; 95% confidence interval, 0.39-2.63, P = .98). Commissures adjusted symmetrically led to lower transvalvular gradient, compared with nonsymmetrical repair (8.7 mm Hg vs 10.2 mm Hg, P = .029).BAV repair, tailored to aorta phenotype, is associated with excellent durable outcomes if both annulus and STJ are reduced and stabilized with external ring annuloplasty. Commissural angle160° is not associated with reoperation if symmetrical repair is achieved.

OBJECTIVES We investigated whether aortic valve fenestrations (respected or fixed) represent a factor associated with recurrent aortic insufficiency or reoperation after repair. METHODS Between 2003 and 2019, patients who underwent aortic valve repair were included. Aortic insufficiency phenotypes were root aneurysm (repair: root remodelling + annuloplasty), ascending aorta aneurysm (repair: tubular aortic replacement + annuloplasty) and isolated regurgitation (repair: single/double annuloplasty). Fenestrations were either respected or fixed according to their features. RESULTS A total of 618 patients (out of 798 operated on; 77.4%) had their valve repaired, with 167 cases of fenestrations (128 were respected, 39 fixed—32 with a patch, 6 with running suture and 1 with both). After conducting propensity score matching between no-fenestration (n = 167) and fenestration groups (n = 167), respectively, we noted the following: survival [90.3% (n = 7 deaths) vs 95.8% (n = 4)], cumulative incidence of reoperation [6.7% (n = 7) vs 5.2% (n = 4)], aortic insufficiency grade ≥ 3 [6.4% (n = 6) vs 4.4% (n = 4)] and grade ≥ 2 [28.9% (n = 28) vs 37.1% (n = 35)] were similar at 9 years [P = 0.94; median follow-up: 2.2, interquartile range: (0.8, 5.8)], whether fenestration was respected (P = 0.55) or fixed (P = 0.6, at 6 years). Standardization of the surgical approach (consisting of double annuloplasty in isolated regurgitation phenotype and expansible subvalvular annuloplasty with effective height assessment with remodelling repair for root aneurysm phenotype) reduced the risk of reoperation (era before standardization: hazard ratio: 5.4, 95% confidence interval: 1.9–15.7, P = 0.002). CONCLUSIONS Fenestration, respected or fixed, is not a factor associated with reoperation or recurrence of significant aortic insufficiency after valve repair if the surgical approach is standardized.

Objective: We propose a novel method to obtainmap patient-specific blood velocity profiles (obtained from imaging data such as 2D flow MRI or 3D colour Doppler ultrasound) and map them to geometric vascular models suitable to perform CFD simulations of haemodynamics. We describe the implementation and utilisation of the method within an open-source computational hemodynamics simulation software (CRIMSON). Methods: tThe proposed method establishes point-wise correspondences between the contour of a fixed geometric model and time-varying contours containing the velocity image data, from which a continuous, smooth and cyclic deformation field is calculated. Our methodology is validated using synthetic data, and demonstrated using two different in-vivo aortic velocity datasets: a healthy subject with normal tricuspid valve and a patient with bicuspid aortic valve. Results: We compare the performance of our method with results obtained with the state-of-the-art Schwarz-Christoffel method, in terms of preservation of velocities and execution time. Our method is as accurate as the Schwarz-Christoffel method, while being over 8 times faster. The proposed method can preserve either the flow rate or the velocity field through the surface, and can cope with inconsistencies in motion and contour shape. Conclusions: Our results show that the method is as accurate as the Schwarz-Christoffel method in terms of maintaining the velocity distributions, while being more computationally efficient.Our mapping method can accurately preserve either the flow rate or the velocity field through the surface, and can cope with inconsistencies in motion and contour shape. Significance: The proposed method and its integration into the CRIMSON software enable a streamlined approach towards incorporating more patient-specific data in blood flow simulations.

Background: Systolic aortic root expansion is reported to facilitate valve opening, but the precise dynamics remain unknown. A sonometric study with a high data sampling rate (200 to 800 Hz) was conducted in an acute ovine model to better understand the timing, mechanisms, and shape of aortic valve opening and closure. Methods: Eighteen piezoelectric crystals were implanted in 8 sheep at each annular base, commissures, sinus of Valsalva, sinotubular junction, nodulus of Arantius, and ascending aorta (AA). Geometric changes were time related to pressures and flows. Results: The aortic root was hemodynamically divided into left ventricular (LV) and aortic compartments situated, respectively, below and above the leaflets. During isovolumetric contraction (IVC), aortic root expansion started in the LV compartment, most likely due to volume redistribution in the LV outflow tract below the leaflets. This expansion initiated leaflet separation prior to ejection (2.1%±0.5% of total opening area). Aortic compartment expansion was delayed toward the end of IVC, likely related to volume redistribution above the leaflets due to accelerating aortic backflow toward the aortic valve and coronary flow reduction due to myocardial contraction. Maximum valve opening during the first third of ejection acquired a truncated cone shape [leaflet free edge area smaller than annular base area (−41.5%±5.5%)]. The distal orifice became clover shaped because the leaflet free edge area is larger than the commissural area by 16.3%±2.0%. Conclusions: Aortic valve opening is initiated prior to ejection related to delicate balance between LV, aortic root, and coronary dynamics. It is clover shaped at maximum opening in systole. A better understanding of these mechanisms should stimulate more physiological surgical approaches of valve repair and replacement.

The bicuspid aortic valve (BAV) is the most common congenital cardiovascular anomaly and may present with differing phenotypes including almost constant annular dilation. We have developed a standardized approach to BAV repair with a systematic adjunct of aortic annuloplasty according to the three phenotypes of the proximal aorta, which include a dilated aortic root, dilated ascending aorta and normal root and ascending aorta. In our cohort of 191 patients, freedom from AV-related re-intervention was 98% for remodeling with annuloplasty (n=100) and 100% for tubular aortic replacement with annuloplasty (n=31) at 8 years. In an isolated aortic insufficiency (AI) group, freedom from AV-related re-intervention varied from 72.4% with a single subvalvular annuloplasty ring (n=31) compared to 100% at 6 years when a double sub- and supra-valvular (STJ) annuloplasty ring was performed (n=29). Restoration of the annulus: sinotubular junction (STJ) ratio is a key factor to ensure longevity of the bicuspid valve repair and freedom from re-intervention.

The growing expertise in valve sparing root replacement over the years (1) has paved the way for developing isolated aortic valve (AV) leaflet repair as an alternative to replacement, especially when a standardized systematic approach in term of annulus and sinotubular junction (STJ) stabilization is utilized. Since 2003, we have developed a standardized systematic approach for AV repair which incorporates leaflet repair and the stabilization of annulus and STJ with double sub and supra (STJ) valvular external ring annuloplasties (Figure 1). Open in a separate window Figure 1 Double sub and supra valvular ring annuloplasty for isolated AI repair (drawing with kind permission of Dr Pavel Zacek).

Aortic valve surgery in non-elderly patients represents a very challenging patient population. The younger the patient is at the point of aortic valve intervention, the longer their anticipated life expectancy will be, with longer exposure to valve-related complications and risk for re-operation. Although the latest international guidelines recommend aortic valve repair in patients with aortic valve insufficiency, what we see in the real world is that the vast majority of these aortic valves are replaced. However, current prosthetic valves has now been shown to lead to significant loss of life expectancy for non-elderly patients up to 50% for patients in their 40s undergoing mechanical aortic valve replacement. Bioprostheses carry an even worse long-term survival, with higher rates of re-intervention. The promise of trans-catheter valve-in-valve technology is accentuating the trend of bioprosthetic implantation in younger patients, without yet the appropriate evidence. In contrast, aortic valve repair has shown excellent outcomes in terms of quality of life, freedom from re-operation and freedom from major adverse valve-related events with similar life expectancy to general population as it is also found for the Ross procedure, the only available living valve substitute. We are at a time when the paradigm of aortic valve surgery needs to change for the better. To better serve our patients, we must acquire high quality real-world evidence from multiple centers globally - this is the vision of the AVIATOR registry and our common responsibility.

Standardization of aortic valve repair techniques with use of a calibrated annuloplasty have led to improved long-term outcomes in dystrophic aortic insufficiency. It can also improve dissemination of techniques and rates of aortic valve repair. Dystrophic aortic insufficiency can be found in three aortic phenotypes: dilated aortic root, dilated ascending aorta and isolated aortic insufficiency. The aortic annulus is invariably dilated above 25 mm in the vast majority of cases of aortic insufficiency, regardless of whether the aorta is dilated or not. A dilated annulus is a risk factor for late failure of aortic valve repair if not addressed at the time of surgery. We perform a calibrated annuloplasty at both sub- and supra-valvular levels in order to restore the ratio of sinotubular junction and annulus. Current evidence shows aortic valve repair reduces valve-related mortality compared to prosthetic valve replacement, with an improved quality of life.

Dystrophic aortic insufficiency accounts for the majority of Western cases of aortic insufficiency and can be divided into the three phenotypes of isolated aortic insufficiency, dilated aortic root, and dilated ascending aorta. Each of these phenotypes is associated with a dilated annulus and/or sinotubular junction. Recent international guidelines recommend reimplantation or remodeling with aortic annuloplasty for valve-sparing root replacement, as well as consideration of aortic valve repair in cases of aortic insufficiency. A dilated aortic annulus is a major risk factor for failure of aortic valve repair procedures, indicating the need to address the annulus at the time of aortic valve or root repair. Calibrated annuloplasty should be performed at sub- and supravalular levels in order to restore the ratio of the sinotubular junction and annulus and be adapted according to the phenotype of the root and ascending aorta. Standardization of aortic valve repair techniques with use of a calibrated annuloplasty will improve dissemination of techniques and rate of aortic valve repair. Current medical evidence shows that aortic valve repair is safe, produces better quality of life, and reduces valve-related mortality compared to prosthetic valve replacement.

In this work, we describe the CRIMSON (CardiovasculaR Integrated Modelling and SimulatiON) software environment. CRIMSON provides a powerful, customizable and user-friendly system for performing three-dimensional and reduced-order computational haemodynamics studies via a pipeline which involves: 1) segmenting vascular structures from medical images; 2) constructing analytic arterial and venous geometric models; 3) performing finite element mesh generation; 4) designing, and 5) applying boundary conditions; 6) running incompressible Navier-Stokes simulations of blood flow with fluid-structure interaction capabilities; and 7) post-processing and visualizing the results, including velocity, pressure and wall shear stress fields. A key aim of CRIMSON is to create a software environment that makes powerful computational haemodynamics tools accessible to a wide audience, including clinicians and students, both within our research laboratories and throughout the community. The overall philosophy is to leverage best-in-class open source standards for medical image processing, parallel flow computation, geometric solid modelling, data assimilation, and mesh generation. It is actively used by researchers in Europe, North and South America, Asia, and Australia. It has been applied to numerous clinical problems; we illustrate applications of CRIMSON to real-world problems using examples ranging from pre-operative surgical planning to medical device design optimization., Author summary We provide the first full presentation in the literature of CRIMSON, the Cardiovascular Integrated Modelling and Simulation Package. CRIMSON consists of a graphical user interface desktop computer program for creating geometric models of blood vessels from medical imaging scans, specifying parameters such as the stiffness of the artery walls, the resistance of connected vessels which are not visible on the scans, and determining the appropriate parameters for all aspects of the model. CRIMSON additionally consists of the Flowsolver, a high-performance computing package which simulates the flow of blood through the models created in the graphical user interface. Whilst several packages which can simulate blood flow exist, most target general fluid simulations, and this lack of specialisation means that blood flow simulation is harder to perform, and can require ad hoc (and potentially scientifically-limiting) workflow decisions. CRIMSON’s specialisation deals with these problems, as well as presenting a number of unique features which are unavailable elsewhere.

Background Recent guidelines support more aggressive surgery for aneurysms of the ascending aorta and root in patients with bicuspid aortic valve. However, the fate of the arch after surgery of the root and ascending aorta is unknown. We set out to assess outcomes following root and ascending aortic surgery and subsequent growth of the arch. Methods Between 2005 and 2016, 536 consecutive patients underwent surgery for aneurysm of the root and ascending aorta; 168 had bicuspid aortic valve. Patients with dissection were excluded. Arch diameter was measured before and after surgery, at 6 months and then annually. Results Of 168 patients, 127 (75.6%) had aortic root replacement and 41 (24.4%) had ascending replacement. Mean age was 57 ± 12.8 years, 82.7% were men, and 5 operations were performed during pregnancy. There was 1 (0.6%) hospital death. One (0.6%) patient had a stroke and 1 (0.6%) had resternotomy for bleeding. Median intensive care unit and hospital stays were 1 and 6 days, respectively. Follow-up was complete for 94% at a median of 5.9 years (range, 1 to 139 months). Aortic arch diameter was 2.9 cm preoperatively and 3.0 cm at follow-up. There was 97% freedom from reoperation and none of the patients required surgery on the arch. Conclusions Prophylactic arch replacement during aortic root and ascending aortic surgery in patients with bicuspid aortic valve is not supported. Our data do not support long-term surveillance of the rest of the aorta in this population.

Traumatic pseudoaneurysms of the aortic arch are often treated with surgical repair regardless of the lesion size or age. The authors report a simple, less invasive surgical repair in a patient who sustained blunt aortic injury following a fall.

Available evidence shows that aortic valve repair reduces valve-related mortality and improves quality of life compared to prosthetic aortic valve replacement. One of the most important predictors of bicuspid and tricuspid aortic valve repair failure is the absence of treating a dilated aortic annulus greater than 25–28 mm. Competency of the aortic valve depends on multiple factors including the diameter of the annulus, sinotubular junction, valve cusps and commissures. Dystrophic aortic insufficiency (AI) is the commonest cause of AI in the Western world and is characterised by dilatation of the aortic annulus (≥25 mm), sinuses and/or sinotubular junction (≥30 mm). Depending on whether the sinuses of Valsalva and/or tubular ascending aorta are dilated, three phenotypes can be identified: dilated aortic root, dilated ascending aorta and isolated AI. All three phenotypes are associated with a dilated aortic annulus. Aortic annuloplasty reduces the dilated aortic annulus and improves the surface of coaptation, as in the case of mitral valve repair. In treating AI, it is also important to restore the physiological sinotubular junction/annulus ratio, which can be carried out with remodeling root repair + subvalvular annuloplasty (for dilated aortic root), tubular ascending aorta replacement + subvalvular annuloplasty (for dilated ascending aorta) and double sub- and supra-valvular annuloplasty (for isolated AI). Aortic annuloplasty is now considered an essential component of aortic valve repair and valve-sparing root surgery.

Recent international guidelines on the management of aortic root disease mention “aortic annuloplasty” in combination with aortic root remodeling as part of a class I indication for management of aortic root aneurysm (1). The remodeling technique provides physiological cusp movement within three reconstructed neo-sinuses, which permits root expansibility through the interleaflet triangles. We have developed a standardized aortic valve and root repair protocol involving a physiological reconstruction of the aortic root using the remodeling technique, cusp effective height resuspension, and a subvalvular external aortic ring annuloplasty (Figure 1). Open in a separate window Figure 1 Remodeling root repair with external aortic ring annuloplasty (drawing with kind permission of Dr. Pavel Zacek).

There is evidence that high surgical volume and team consistency improve outcomes. Mortality of 4%-12% for aortic root surgery has been reported in the United States and UK. We aim to assess outcomes of patients undergoing aortic root surgery by a consistent, high-volume team. Data on patients undergoing elective or urgent aortic root replacement (ARR) were collected prospectively. Patients undergoing emergency surgery were excluded. A standardized perioperative approach was maintained and was achieved by delivering training to team members, including surgical trainees, anesthetic, nursing, and perfusion staff, whenever there was a change of team. Between 2005 and 2014, 344 patients underwent ARR. Median age was 59 years (18-86) and 74% were men. Procedures included ARR (biological [186; 54%] or mechanical [101; 29.4%]) and valve sparing root replacement, remodeling technique (57; 16.6%). A total of 42 patients (12.2%) underwent concomitant procedures. There were 4 (1.2%) in-hospital deaths and no incidence of stroke. In total, 3 (0.9%) required resternotomy for bleeding and 8 (2.3%) required hemofiltration. Follow-up was complete for 94% of patients with median intensive care unit and hospital stays of 1 and 6 days, respectively. Follow-up was complete for 94% of patients at a median of 5.6 years with 98% freedom from reoperation and prosthetic valve dysfunction. There was 90% freedom from aortic insufficiency at 7 years in the valve sparing root replacement, remodeling technique cohort. We have demonstrated that high surgical volume and standardized care improves outcomes in aortic root surgery. Maintaining a consistent perioperative approach ensures team members are aware and well rehearsed in their roles, thereby improving outcomes.

Both genetic and haemodynamic theories explain the aetiology, progression and optimal management of bicuspid aortic valve aortopathy. In recent years, the haemodynamic theory has been explored with the help of magnetic resonance imaging and computational fluid dynamics. The objective of this review was to summarize the findings of these investigations with focus on the blood flow pattern and associated variables, including flow eccentricity, helicity, flow displacement, cusp opening angle, systolic flow angle, wall shear stress (WSS) and oscillatory shear index. A structured literature review was performed from January 1990 to January 2018 and revealed the following 3 main findings: (i) the bicuspid aortic valve is associated with flow eccentricity and helicity in the ascending aorta compared to healthy and diseased tricuspid aortic valve, (ii) flow displacement is easier to obtain than WSS and has been shown to correlate with valve morphology and type of aortopathy and (iii) the stenotic bicuspid aortic valve is associated with elevated WSS along the greater curvature of the ascending aorta, where aortic dilatation and aortic wall thinning are commonly found. We conclude that new haemodynamic variables should complement ascending aorta diameter as an indicator for disease progression and the type and timing of intervention. WSS describes the force that blood flow exerts on the vessel wall as a function of viscosity and geometry of the vessel, making it a potentially more reliable marker of disease progression.

OBJECTIVES: Significant proportions of aortic dissections occur at aortic diameters 10 cm2/m, are at increased risk of aortic complications. METHODS: IAAs were calculated at 3 aortic locations in 187 aneurysm and 66 dissection patients operated on between 2010 and 2016 at our tertiary aortic centre. Proportions of patients with IAA >10 cm2/m, mean IAAs corresponding to aortic diameters 5.5 cm, and mean aortic diameters corresponding to IAAs 10-12 cm2/m, 12-14 cm2/m and >14 cm2/m were determined. RESULTS: Proportions of patients with abnormal IAAs were similar in both groups. In all, 49.1% of aneurysm patients with aortic diameters 4.5-5.0 cm, and 98.5% with aortic diameters 5.0-5.5 cm had abnormal IAAs. Out of 207 separate aneurysms with IAAs >10 cm2/m between the mid-sinus and mid-ascending aorta, only 139 (69.5%) would warrant surgery according to existing guidelines. CONCLUSIONS: Using the IAA, we identified a significant proportion of patients with thoracic aortic aneurysms who are at increased risk of aortic complications, despite current aortic guidelines not endorsing surgical intervention in this group. Our data suggests the IAA may be useful in preoperative risk evaluation and as a criterion for surgery.

Objective: Repair of combined dystrophic mitral and aortic insufficiency (AI) remains a challenge. We report outcomes of a standardized repair approach using mitral and aortic ring annuloplasty.Met...

Introduction Treatment guidelines for the thoracic aorta concentrate on size, yet acute aortic dissection or rupture can occur when aortic size is below intervention criteria. Functional imaging and computational techniques are a means of assessing haemodynamic parameters involved in aortic pathology. Sources of data Original articles, reviews, international guidelines. Areas of agreement Computational fluid dynamics and 4D flow MRI allow non-invasive assessment of blood flow parameters and aortic wall biomechanics. Areas of controversy Aortic valve morphology (particularly bicuspid aortic valve) is associated with aneurysm of the ascending aorta, although the exact mechanism of aneurysm formation is not yet established. Growing points Haemodynamic assessment of the thoracic aorta has highlighted parameters which are linked with both clinical outcome and protein changes in the aortic wall. Wall shear stress, flow displacement and helicity are elevated in patients with bicuspid aortic valve, particularly at locations of aneurysm formation. Areas timely for developing research With further validation, functional assessment of the aorta may help identify patients at risk of aortic complications, and introduce new haemodynamic indices into management guidelines.

Computational fluid dynamics (CFD) provides a noninvasive method to functionally assess aortic hemodynamics. The thoracic aorta has an anatomically complex inlet comprising of the aortic valve and root, which is highly prone to different morphologies and pathologies. We investigated the effect of using patient-specific (PS) inflow velocity profiles compared to idealized profiles based on the patient's flow waveform. A healthy 31 yo with a normally functioning tricuspid aortic valve (subject A), and a 52 yo with a bicuspid aortic valve (BAV), aortic valvular stenosis, and dilated ascending aorta (subject B) were studied. Subjects underwent MR angiography to image and reconstruct three-dimensional (3D) geometric models of the thoracic aorta. Flow-magnetic resonance imaging (MRI) was acquired above the aortic valve and used to extract the patient-specific velocity profiles. Subject B's eccentric asymmetrical inflow profile led to highly complex velocity patterns, which were not replicated by the idealized velocity profiles. Despite having identical flow rates, the idealized inflow profiles displayed significantly different peak and radial velocities. Subject A's results showed some similarity between PS and parabolic inflow profiles; however, other parameters such as Flowasymmetry were significantly different. Idealized inflow velocity profiles significantly alter velocity patterns and produce inaccurate hemodynamic assessments in the thoracic aorta. The complex structure of the aortic valve and its predisposition to pathological change means the inflow into the thoracic aorta can be highly variable. CFD analysis of the thoracic aorta needs to utilize fully PS inflow boundary conditions in order to produce truly meaningful results.

One of the cardinal features of Marfan Syndrome (MFS) is involvement of the cardiovascular system, with predominant effect on the thoracic aorta. The most life-threatening complication of MFS is aneurysm of the thoracic aorta. This can lead to acute aortic dissection or rupture. The mainstay of surgical treatment of the thoracic aorta in Marfan patients is to prophylactically replace or repair part of the thoracic aorta before dissection or rupture occurs. However, it also encompasses emergency surgical management of acute aortic dissection when this lethal disorder does present itself.

Fast-track (FT) management of cardiac surgery patients is associated with early extubation and reduced length of intensive care unit (ICU) stay, with potential benefit of reduced hospital costs. The authors examined perioperative factors and their influence on failure of FT and what implications this failure had.Prospective data collection from all adult cardiac surgeries between 2011 and 2013.Single-institution study.The study included 2,770 consecutive adult cardiac surgery patients.All participants underwent adult cardiac surgeries. Of those, 451 (16.3%) patients were selected to undergo FT management.Failure of FT was defined as early (admission to ICU on day of surgery) or late (patients later admitted to the ICU from the ward). Univariate and multivariate regression analyses were used to identify which variables predicted FT failure. Of the 451 patients included in this study, 138 (30.6%) failed the FT, with 115 (83.3%) early failures and 23 (16.7%) late failures. Predictors of failure were reduced renal function, hypertension, age, EuroSCORE, cardiopulmonary bypass time, first lactate or base deficit after surgery (all p0.01), and cross-clamp time (p0.05). Multivariate analysis showed that the strongest predictor of failure was glomerular filtration rate (GFR)65 mL/min/BSA (sensitivity, 54%; specificity, 61%; likelihood ratio, 1.39; area under receiver operating characteristics curve, 0.59; 95% confidence interval, 0.53-0.64). Median length of hospital stay was longer for the failed group (5 v 7 days, p0.001). There were no mortalities in any of the patients selected for FT.A number of perioperative factors are associated with failure to FT, the strongest predictor being GFR. Failure to FT can lead to significantly longer hospital stay.

Spontaneous coronary artery dissection is a rare but important differential diagnosis in fit young women presenting with chest pain.

Introduction Current intervention criteria for the thoracic aorta concentrate on size. However, the complexity of aortic disease is not fully exposed by aortic dimensions alone, and morbidity or mortality can occur before intervention thresholds are reached. Computational fluid dynamics (CFD) is a non-invasive approach to quantify haemodynamics in assessment of aneurysms and rupture risk. Wall shear stress (WSS) measuring viscous shearing forces on the endothelium, and oscillatory shear index (OSI) measuring disturbed flow, are a pathophysiological stimulus to gene expression, extracellular-matrix remodelling, and aortic wall thinning. We aimed to evaluate the efficacy of a new patient-specific approach to CFD of the thoracic aorta, and its functional and haemodynamic indices in assessment of aortic pathology. Methods 45 subjects were divided into 5 groups: Volunteers, AR-TAV, AS-TAV, AS-BAV(RL), AS-BAV(RN), where AR=aortic regurgitation, AS=aortic stenosis, TAV=tricuspid aortic valve, BAV=bicuspid aortic valve, RL=right-left cusp fusion, RN=right-non cusp fusion. Subjects underwent magnetic resonance angiography, with phase-contrast MRI at the sino-tubular junction to define patient-specific inflow velocity profiles. Three-dimensional aorta models were constructed from MRA data and discretized to form a finite element mesh. The 3D velocity profile from PC-MRI was mapped onto the inflow mesh, allowing prescription of patient-specific inflow boundary conditions. Blood pressure, cardiac output, and cross-sectional area of each vessel were processed to assign outflow boundary conditions to arch vessels and descending aorta. Results CFD enabled measurement of WSS throughout the thoracic aorta. WSS was significantly elevated in aortic stenosis, highest in AS-BAV(RN) (mean WSS=37.1 ± 4.0 dyn/cm2, compared to 19.9 ± 1.9 dyn/cm2 for AS-BAV(RL), 25.7 ± 1.2 dyn/cm2 in AS-TAV, 12.3 ± 3.4 dyn/cm2 in AR-TAV, and 9.9 ± 5.4 dyn/cm2 in healthy volunteers, p Eccentricity of flow was higher in bicuspid patients (Flowasymmetry= 84.1 ± 5.4%, compared to 28.1 ± 21.5 for tricuspids, p Conclusions BAV displays eccentric flow with high helicity. Presence of AS, particularly in BAV-RN led to higher WSS and lower OSI in the greater curvature of the ascending aorta. Patient-specific CFD provides non-invasive functional assessment of the thoracic aorta, and enables development of a personalized approach to diagnosis and management of aortic disease beyond traditional guidelines.

ADAMTS, aneurysm, ECM Introduction Thoracic aortic aneurysms (TAA) are common in patients with bicuspid aortic valve (BAV). ADAMTS-1 (a disintegrin and metalloproteinase with thrombospondin motifs) has recently been implicated in TAA formation (Oller et al, Nat Med, 2017). The contribution of other ADAMTS proteases to TAA is currently unknown. Method Using proteomics, we compared the extracellular matrix (ECM) composition in the greater (i.e. the aneurysm-prone area) and lesser curvatures of TAA in BAV patients. Our findings in patients were complemented by studies in ADAMTS-5 deficient mice. Results In BAV patients with TAA, the large aggregating proteoglycan versican was the most differentially regulated ECM protein in the aneurysm-prone area. In mice, ADAMTS-5 is the main versican-degrading member of the ADAMTS family. Hence, a model of aortic dilatation by angiotensin II (AngII) infusion was adopted in mice lacking the catalytic domain of ADAMTS-5 (Adamts-5cd). AngII treatment raised blood pressure in wild-type (WT) mice; this response was attenuated and associated with increased dilation of the ascending aorta in Adamts-5cd mice. Concomitantly, versican accumulation and reduced versican degradation products were observed in Adamts-5cd aortas compared to WT controls. The presence of other ADAMTS members, including ADAMTS-1, was not sufficient to maintain versican processing and prevent aortic dilation in Adamts-5cd mice. Conclusion Our results support the emerging role of ADAMTS proteases in TAA. ADAMTS-5 rather than ADAMTS-1 is the key protease for versican regulation in murine aortas. Further studies are needed to define the ECM substrates of the different ADAMTS proteases and their contribution to TAA formation.

ObjectivesThe complexity of aortic disease is not fully exposed by aortic dimensions alone, and morbidity or mortality can occur before intervention thresholds are met. Patient-specific computational fluid dynamics (CFD) was used to assess effect of different aortic valve morphologies on velocity profiles, flow patterns, helicity, wall shear stress (WSS) and oscillatory shear index (OSI) in the thoracic aorta.Methods45 subjects were divided into 5 groups: Volunteers, AR-TAV, AS-TAV, AS-BAV(RL), AS-BAV(RN), where AR=aortic regurgitation, AS=aortic stenosis, TAV=tricuspid aortic valve, BAV=bicuspid aortic valve, RL=right-left cusp fusion, RN=right-non cusp fusion. Subjects underwent magnetic resonance angiography, with phase-contrast MRI at the sino-tubular junction to define patient-specific inflow velocity profiles. Hemodynamic recordings were used alongside MRI angiographic data to run patient-specific CFD.ResultsBAV groups had larger mid-ascending aorta diameters (pasymmetry=78.9±6.5% for AS-BAV(RN), compared to 4.7±2.1% for Volunteers, p2, compared to 9.8±5.4 for Volunteers, pConclusionsBAV displays eccentric flow with high helicity. Presence of AS, particularly in BAV-RN led to higher WSS and lower OSI in the greater curvature of the ascending aorta. Patient-specific CFD provides non-invasive functional assessment of the thoracic aorta, and may enable development of a personalized approach to diagnosis and management of aortic disease beyond traditional guidelines.

Chordomas are midline tumors of notochordal origin, occurring anywhere from the skull base to the coccyx. Although one-third of chordomas occur in the sphenooccipital region, to our knowledge only 1 case of jugular foramen chordoma with unusual extension into the neck has been reported in the literature to date. A 21-yearold woman presented with a 3-year history of a large neck mass and partly compensated lower cranial nerve symptoms of insidious onset. Imaging revealed a tumor involving the posterior cranial fossa and carotid space, with widening and erosion of the jugular foramen. Characteristic histopathologic findings and immunohistochemical staining confirmed the diagnosis. The tumor was removed by a combined retrosigmoid and lateral cervical approach. The patient was disease free 18 months after treatment.

The aim was to explore the impact of important clinico-demographic factors on the post-treatment quality of life (QOL) in surgically treated oral and oropharyngeal cancer patients. 63 consecutive follow-up oral and oropharyngeal cancer patients treated primarily with surgery were recruited. 55 patients sent the completed questionnaires and finally included in this study. QOL and important sub-domains of the QOL were assessed. Mean QOL scores (SD) were computed, level of significance was set at P < 0.05. The mean composite QOL score and standard deviation (SD) for oral and oropharyngeal cancer patients were 76.6 (15.2) and 73.4 (13.9), respectively. Patients with higher T-stage (T3 and T4) and higher overall-stage (III and IV) had lower mean QOL scores as against early T (T1 and T2) and overall early-stage (I and II); mean scores (SD) 64.3 (13.6) and 72.3 (13.8), and 76.6 (13.6) and 81.7 (14.1), respectively. Younger patients had lower mean scores (SD) than older patients; mean QOL scores (SD) 69.7 (14.0) and 79.6 (SD), respectively. Patients with reconstruction had lower mean QOL scores as compared to those without reconstruction; mean scores (SD) 67.6 (16.0) and 77.4 (12.5), respectively. In conclusion, tumor-stage, overall-stage, age of patients, and reconstruction had a significant direct effect on the post-treatment QOL of oral and oropharyngeal cancer patients.

s / International Journal of Surgery 8 (2010) 501–578 558 Objective: To assess adherence to previously published guidelines in acoustic neuroma screening. Acoustic neuromas commonly present with asymmetrical sensorineural hearing loss. Strict criteria for asymmetry have been developed to appropriately and cost-effectively scan (MRI) for this tumour. Setting: Otolaryngology department of a teaching hospital with a tertiary referral lateral skull base practice. Method: Review of 100 patients in whom MRI scans had been requested for asymmetrical sensorineural hearing loss was undertaken. Their audiograms were compared with guidelines giving specific audiometric criteria for scanning previously published by our department 6 years previously. Results: whilst the protocol was adhered to in many cases, there was a significant number inwhich scans were inappropriately requested, as the asymmetry did not meet the expected audiometric criteria. This may be due to frequent turnover of junior staff, which has increased in recent years. Conclusion: A re-education programme was undertaken and new staff will be made aware of the guidelines at their departmental induction. Appropriate requests for MRI scans will have cost savings and prevent unnecessary patient anxiety. THE LYMPH NODE YIELD OF NECK DISSECTIONS – IS THERE A DIFFERENCE BETWEEN CONSULTANT SURGEONS AND SPECIALIST REGISTRARS? P. Youssefi, C.E.B. Giddings, F. Amen, P. Rhys-Evans, P.M. Clarke, C.J. Kerawala. The Royal Marsden Hospital Aims: To compare the lymph node yield in neck dissections carried out by consultant surgeons and specialist registrars at a single centre. Methods: Retrospective analysis of 80 neck dissections over 4 years for total number of lymph nodes excised in each of the cervical oncological levels. For each year, the last 10 neck dissections carried out by specialist registrars during their one year training at the centre were analyzed, with the last 10 neck dissections carried out by consultant surgeons. Eight registrars at different stages of training and three consultant head and neck surgeons were used. Comparison was made between the two groups for each of the six oncological levels (and sub-levels). Results: Independent t-test analysis showed there were no statistically significant differences in lymph node yield for any oncological levels between consultant surgeons and specialist registrars (p >0.05). The most notable difference, albeit non-significant, was for Level III lymph nodes, with consultants yielding a mean 6.5 lymph nodes (n 1⁄4 38) and registrars yielding 4.5 lymph nodes (n 1⁄4 24) (p 1⁄4 0.08). Conclusion: The lymph node yield of neck dissections carried out by specialist registrars towards the end of their year of head and neck training does not differ significantly from consultants. GALLBLADDER ASPIRATION ROUTINELY FOR LAPAROSCOPIC CHOLECYSTECTOMY M.R.S. Siddiqui, R. Gyanti, A. Zaborszky, F. Hasan. Benenden Hospital, Cranbrook, Kent, UK Objectives: A meta-analysis of published literature comparing outcomes after aspirating (ASP) the gallbladder versus non-aspiration (NASP). Methods: Electronic databases were searched from January 1985 to November 2009. A meta-analysis was performed to obtain a summative outcome. Results: Two randomized controlled trials involving 360 patients were analyzed. 180 patients were in the ASP group and 180 in the NASP group. There was no significant increase in operative time in the ASP group compared with the NASP group [random effects model: SMD 1⁄4 -0.72, 95% CI (-2.16, 0.71), z 1⁄4 0.99, df 1⁄4 1, p 1⁄4 0.32] but there was significant heterogeneity amongst trials [Q 1⁄4 42.4, p